- Is coronary angiogram still the gold standard for Non ST Elevation MI imaging?
- Large STEMI and haemodynamically crushing patient
- A complex and complicated TAVI case
- Advanced coronary and carotid disease in a patient undergoing non-cardiac surgery
- Coronary stenoses are meant to be stented: who cares about the rest!
- Institut Cardiovasculaire Paris Sud Massy - France
- CTO of ostial LAD (retrograde technique)
CTO of ostial LAD (retrograde technique)
- Live center: Institut Cardiovasculaire Paris Sud Massy - France
- Operators: Osamu KATOH, T. LEFEVRE, Mohamed ABDELLAOUI
- Patient: CC, male, 72 y.o.
- Type of procedure: Coronary
- Level: Complex
- Access type: Retrograde, Femoral
Euroscore: 3 (predicted mortality from CABG: 2.1)
Silent myocardial ischemia
Positive stress test
- Length: 40
- Retinal vessel diameter: 3.5
- Lesion subset: Chronic total occlusion of ostial LAD with collateral circulation from the RCA
- Therapeutic techniques: Retrograde approach
Retrograde approach via the septal collaterals ?
Should we attempt this lesion ?
What is the optimal approach to this kind of lesion ?
How to perform the retrograde approach ?
|Maverick 2 ™ Monorail||Balloon||2 x 20||x 1|
|Maverick||Balloon||2.5 x 23||x 1|
|Maverick||Balloon||3 x 20||x 1|
|Promus||Stent||2.5 x 28||x 1|
|Promus||Stent||2.5 x 23||x 1|
|CORDIS, a Johnson & Johnson Company|
|Dura Star||Balloon||3 x 15||x 1|
|Cypher Select||Stent||2.5 x 28||x 1|
|Lacrosse Balloon||Balloon||1.3 x 10||x 1|
|ASAHI NEO´S||Guide wire||x 3|
|X-treme wire||Guide wire||x 1|
|JR 4 7F||Catheter||x 1|
|EBU 4 8F||Catheter||x 1|
|Femoral 7F||Introducer Sheath||x 1|
|Femoral 8F||Introducer Sheath||x 1|
|Finecross 1.8F||Catheter||x 1|
Take home message
Safety and effectiveness of the retrograde approach in selected cases of chronic occlusion
MSCT demonstrated that the occlusion was of the mid LAD after the first diagonal branch
EBU 4.0 8F guiding catheter in LMS. BMW wire in first diagonal. IVUS examination of proximal LAD to locate entry into true lumen.
24/05/2007: RCA cannulation with JR4 7F guiding catheter in preparation for retrograde approach caused ostial dissection - treated by deployment of a single 4.5 x 24mm PROMUS stent
1st and 2nd diagonal branches wired via antegrade approach. Unable to advance wire into true lumen of LAD. Via retrograde approach, balloon dilatation of septal branch and then wire advanced back through LAD occlusion and into guiding catheter.
Distal LAD lumen now visualised and wire advanced antegradely
Predilatation of proximal and mid LAD and bifurcation (kissing inflation 2.5 and 2.0mm Maverick). Stenting of Mid LAD: PROMUS 2.5 X 28mm, then 2.5 x 23mm PROMUS distally.
After final kissing inflation: LAD 3mm, Diagonal 2.5mm Maverick; Final good angiographic result in LAD and diagonal. Distal LCX treated with PROMUS 2.5 x 15mm afterwards.
Patient currently asymptomatic.Normal dobutamine stress echocardiogram.Angiography at 9 months satisfactory showing no restenosis.
Second view of good result of ostial LAD stenting at 9 months.